Employers, doctors design outcomes standards
Employers, doctors design outcomes standards
The Stillwater (MN) Medical Group, part of the St. Croix Valley HealthCare system, was one of eight clinics whose physicians founded the Institute for Clinical Systems Integration (ICSI) in Bloomington, MN. An unprecedented event in 1993 started the wheels turning.
When a group of Minneapolis and St. Paul, MN self-insured employers formed a health-benefits purchasing coalition called Buyers Health Care Action Group (BHCAG), they told the contracting provider systems, "We want to meet with the providers."
At that, notes Audrey Hansen, RN, PHN, director of clinical practice for the St. Croix Valley HealthCare system, "Their jaws dropped! It was a brand-new idea to the doctors. But it made sense — the employers wanted to know if spending all that money was doing any good for their employees’ health."
When the employers laid out their terms, however, things got tense. They wanted to compare outcomes among all the providers from whom they purchased health care. At which, the physicians protested with cries of "cookbook medicine."
No fools when it came to negotiation, the employers asked the doctors to design the practice guidelines by which their practices would be compared. By being involved on a volunteer basis," Hansen notes, "the physicians embraced the guidelines they developed and gradually formed habits of practicing evidence-based medicine."
The members of ICSI now have a model for evaluating the literature and writing guidelines for use throughout the BHCAG provider network. Often, Hansen comments, if they come up against something where they don’t have common procedures, they’ll go to ICSI and initiate a guideline.
Fine-tuning the process
Not for a moment does Hansen say that selling guideline and evidence-based care practices was easy. Some clinicians think in linear fashion, so seeing algorithms leading to medical decisions reflected their thought processes. "But some of them who don’t use linear decision making freaked until they understood how the algorithms worked," she recalls.
Hansen kept them aware that quality improvement initiatives must include the patient’s as well as the provider’s perspective. "Instead of making this network the best environment for the physician to practice," she explains, "we have ensured that every guideline includes the concern for how it’s working for the patient."
Patricia Drury, MBA, senior consultant for quality measurement and consumer information for BHCAG echoes Hansen’s point, stressing that patient satisfaction is as vital to the employers as good care. She regularly reminds BHCAG providers, "You may be doing everything wonderfully, but if people hate you, you are not conveying that message."
Here’s an example of how, over a four-year period, practice guidelines streamlined urinary tract infection (UTI) treatment and boosted patient satisfaction:
1. Telephone screening by a nurse replaced doctor’s office visit.
If the symptoms and the woman’s overall health status pointed to a UTI without complications, the patient simply took a urine sample to the outpatient clinic and picked up her antibiotics.
That garnered overwhelming patient satisfaction gains on the urgent care surveys. Although numbers on the cost savings from the change were not available, anecdotal evidence indicates they were substantial.
2. Routine urinalysis was eliminated.
Patient records confirmed reliability of nurses’ phone screenings in detecting indicators of complications.
3. Three-day antibiotics regimens replaced the seven-day regimens.
The literature show overwhelming evidence that short-course antibiotics did the job. This pleased patients because three days of antibiotics cause fewer yeast infections than seven-day courses. Today, better than 90% of UTIs are successfully treated with short courses of antibiotics, and 100% of the treatment ensues without doctor’s office visits or lab work.
(To trace the evolution of this shift in practice, see the UTI guideline, at left.)
Implementing the UTI guideline revealed access problems for doctors’ appointments at Stillwater clinic. Patient feedback cited difficulty in getting appointments as one reason they dreaded seeing a doctor for UTI.
Despite providers’ opinions to the contrary, the data backed up patient complaints "and data tell the truth," Hansen says. To understand the nature and extent of wait times for appointments and telephone advice, she monitored patient complaints. Realizing also that people are quicker to issue complaints than compliments, she moved comment boxes to prominent places in high traffic areas.
By analyzing compliments along with complaints, she can apprise providers on their customer service improvements. She notes that they’re learning how every change affects everything else. Even improvements at one point in the service continuum can create problems somewhere else unless they approach change from a systems perspective. (See graph on the pattern of complaint-compliment feedback, above.)
Gone are the days of selling Stillwater’s doctors on practice guidelines. Today, they own the process. To spread the responsibility as well as the rewards of creating and fine-tuning the 32 guidelines now in use, each has its own "champion." This champion becomes the "resident expert" who stays abreast of emerging research, and communicates with the champions of related guidelines. For example, all the respiratory experts keep in close touch with each other.
"If somebody wants a new toy, like a new mammography machine," Hansen explains, "we pull out the guideline and say go to Dr. X."
While the physicians did the work of developing the guidelines, she adds that the employers of BHCAG couldn’t have imagined the magnitude of the change they set in motion when they said they wanted to monitor the outcomes of employees’ care.
Hansen says she marvels at how far the doctors have come. At this point, they ask how they’re doing compared to other providers in the BHCAG network. If a patient care issue arises and there’s no consensus about how to treat it, "they’ll say we need a guideline,’ and ICSI designs it."
[For more information on introducing clinical practice guidelines, contact Audrey Hansen, Director of Clinical Practice, St. Croix Valley HealthCare, 1500 Curve Crest Blvd., Stillwater, MN 55082. Telephone: (651) 439-1088, ext. 1418.]
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.